EMPLOYEE BENEFITS GUIDE

Transcription

1 EMPLOYEE BENEFITS GUIDE

2 EMPLOYEE BENEFITS GUIDE General Information 01. Contact Information 02. Introduction 03. Eligibility 04. Changes in Coverage 5 Core Benefits 05. Medical 10. Dental 11 Other Benefits 11. Basic Life and Accidental Death & Dismemberment (AD&D), STD and LTD 12. Employee Assistance Program (EAP) 13. Retirement 14. Flexible Spending Accounts 16 Miscellaneous 16. Important Notices The information in this brochure is a general outline of the benefits offered under the s benefits program. Specific details and plan limitations are provided in the Summary Plan Descriptions (SPD), which is based on the official Plan Documents that may include policies, contracts and plan procedures. The SPD and Plan Documents contain all the specific provisions of the plans. In the event that the information in this brochure differs from the Plan Documents, the Plan Documents will prevail.

3 Contact Information Plan Phone Number Web Site Medical Kaiser Permanente Sutter Health Plus Dental Delta Dental Group Life Insurance Standard Insurance Company Short & Long-Term Disability Standard Insurance Company Employee Assistance Program (EAP) MHN (Company Code: elcerrito) Flexible Spending Account (FSA) Benefit Resource Inc Retirement CalPERS Retirement ICMA-RC (Deferred Compensation)

4 General Information Introduction This Benefit Guide is provided to employees as a comprehensive resource for the. This Guide is not intended to be a contract (expressed or implied), nor is it intended to otherwise create any legally enforceable obligation on the part of the City, its agents, or its employees. The purpose of this Guide is to summarize the City s employee benefits and the policies and procedures regarding these benefits. For the most detailed and up to date information please refer to the appropriate plan document, evidence of coverage booklet, insurance policy, or contract. These documents can be obtained by contacting Human Resources. Open Enrollment Open Enrollment is held in June (medical only) and December (dental only) of each year. This is the time you can make changes to your benefits, unless you have an IRS qualifying change of status during the plan year. Please see the Qualifying Events list located on page 3. 2

5 Eligibility Employees The offers Medical, Dental, Group Life/ Accidental Death and Dismemberment, and Disability Insurance to full-time employees and their eligible dependents. The City also offers Flexible Spending Account (FSA) for health care or child care expenses. Dependents When enrolling dependents, appropriate documentation and/or proof of dependent status is required by the City and will be requested by Human Resources. Accepted forms or proof include Marriage and Birth Certificates, Tax Returns, Local City Government or State Issued Declaration of Domestic Partnership, Adoption Certificate or Proof of Legal Guardianship. The following dependents are eligible: Your eligible dependents include your legal spouse, registered domestic partner, and children up to age 26 Children include your natural children and/or legally adopted children Change in Dependent Eligibility Continuation of Coverage for Dependents (COBRA) While you must drop your ineligible dependent within 30 days of the loss of eligibility, failure to drop your ineligible dependent within 60 days of loss of eligibility will result in a loss of continuation of coverage rights (COBRA) for your dependents. Same-sex Marriage Health Benefits On June 26, 2013, the U.S. Supreme Court ruled that the federal ban on recognizing same-sex marriages was unconstitutional. As a result, same-sex married partners who reside in a state in which same-sex marriage is recognized are legally considered married and are to be treated the same as opposite-sex married partners in all respects under Federal and State law, which means they may now be eligible for benefits to which they were not previously entitled for example, payment of health insurance premiums on a pre-tax basis, COBRA continuation rights, and other benefits for which spouses are eligible. Any legally married same sex partner should immediately review his or her employee benefits elections to ensure that he or she is maximizing what is now available to same sex marriage partners. The law has not changed with respect to samesex domestic partners who are not married. It is the employee s responsibility to notify Human Resources within 30 days or sooner of a dependent s change in status that would make the dependent eligible or ineligible for benefit coverage. Some examples of a change in dependent status are birth, death, adoption, or divorce. 3

6 Changes in Coverage Qualifying Events You may experience certain events during the plan year that would allow you to change your or your dependent s medical coverage. If any of the following events occur, you have up to 31 days from the date of the event to elect a change in benefit coverage(s). Change in your legal marital or domestic partner status, including marriage, death of your spouse/ domestic partner, divorce, legal separation, or annulment. Change in the number of your dependents, including birth, adoption, placement for adoption, or death of your dependent. Change in your employment status, including termination or commencement of employment of you, your spouse, your domestic partner, or your dependent. Change in work schedule for you or your spouse/ domestic partner, including an increase or decrease in the number of hours of employment, a switch between full-time and part-time status, a strike, lockout, or commencement or return from an unpaid leave of absence. A change in the place of residence or worksite of you or your spouse/domestic partner (this move must affect your coverage options). You, your spouse/domestic partner, or your dependents lose COBRA coverage. You, your spouse/domestic partner, or your dependents enroll for Medicare or Medicaid or lose coverage under Medicare or Medicaid. If the plan receives a decree, judgment, or court order, including a QMSCSO pertaining to your dependent. A significant change in benefit or cost of coverage for you or your spouse/domestic partner. Your spouse s or domestic partner s employer provides the opportunity to enroll or change benefits during an open enrollment period. Your dependent satisfies or no longer meets the eligibility requirements for dependents. 4

7 Core Benefits Medical The City pays the full premium at the rate of the lowest cost provider (single, +1, or family). If you have insurance coverage elsewhere, the City offers an in-lieu payment at the lowest cost provider s single rate with proof of coverage for yourself and your IRS tax dependents. The offers its employees the choice between a Kaiser HMO and a Sutter Health Plus HMO. Health Maintenance Organizations (HMOs) HMOs allow you to review comprehensive coverage at set prices, called copays. Doctors/ Other Medical Care Providers You can only use doctors, hospitals and pharmacies that participate in the HMO network. Doctors who participate in the HMO network are called in-network providers. There is no coverage if you go to out-of-network providers, except for emergency services. Annual Deductible You don t need to pay an annual deductible before the plan begins to pay a portion of covered medical services. Copays When you receive medical care, you pay a set dollar amount called copay. Annual Out-of-Pocket Maximum The HMO plans include an annual out-of-pocket maximum. This is the maximum amount you must pay out of your own pocket for copays during the plan year. Once you reach the out-of-pocket maximum, the plan pays 100% of covered charges for the remainder of the plan year. 5

8 Medical (continued) Benefit Categories Kaiser Permanente Schedule of Benefits General Plan Information Annual Deductible/Individual $0 Annual Deductible/Family $0 Office Visit/Exam $10 copay Annual Out-of-Pocket Limit/Individual $1,500 Annual Out-of-Pocket Limit/Family $3,000 Deductible Included in Out-of-Pocket Limits Lifetime Plan Maximum Unlimited Primary Care Physician Election Required Yes Preventive Services Well-Child Care 100% Immunizations 100% Well Woman Exams 100% Mammograms 100% Adult Periodic Exams with Preventive Tests 100% Diagnostic X-Ray and Lab Tests 100% Maternity Care Pregnancy and Maternity Care (Pre-Natal Care) 100% Inpatient Hospital Services Inpatient Hospitalization 100% Pre-Authorization of Services Required Yes Semi-Private Room & Board; Including Services and Supplies 100% Surgical Services Outpatient Facility Charge $10 per procedure Emergency Services Emergency Room $10 visit Ambulance Air 100% Ground 100% The information described on this page is only intended to be a summary of benefits. It does not describe or include all benefit provisions, limitations, exclusions, or qualifications for coverage. Please review plan documents for full details. If there are any conflicts with information provided on this page, the plan documents will prevail. 6

9 Medical (continued) Benefit Categories Kaiser Permanente Schedule of Benefits Urgent Care Urgent Care Facility $10 copay Mental Health Benefits Inpatient Care 100% Outpatient Care $10 per visit for individual ; $5 per visit for group Substance Abuse Inpatient Care Inpatient Hospitalization 100% Inpatient Detoxification Services 100% Outpatient Care Outpatient Services $10 per visit for individual ; $5 per visit for group Prescription Drug Benefits Generic $10 copay Preferred Specialty $10 copay Brand (Formulary/Preferred) $10 copay Brand (Non-Formulary/Non-preferred) $10 copay Number of Days Supply 100 days Mail Order Generic $10 copay Preferred Specialty $10 copay Brand (Formulary/Preferred) $10 copay Brand (Non-Formulary/Non-preferred) $10 copay Number of Days Supply for Mail Order 100 days Other Services and Supplies Durable Medical Equipment & Prosthetic Devices 100% Home Health Care 100% part time intermittent care; 3 visits /day; 100 visits/ year Skilled Nursing or Extended Care Facility 100% up to 100 day maximum per benefit period Hospice Care 100% Chiropractic Services $10 copay; 30 visits Acupuncture $10 copay; referral required Infertility Diagnosis Covered. See plan certificate Treatment Covered. See plan certificate Outpatient Rehabilitative Therapy Services Physical $10 copay Occupational $10 copay Speech $10 copay The information described on this page is only intended to be a summary of benefits. It does not describe or include all benefit provisions, limitations, exclusions, or qualifications for coverage. Please review plan documents for full details. If there are any conflicts with information provided on this page, the plan documents will prevail. 7

10 Medical (continued) Benefit Categories Sutter Health Plus Schedule of Benefits General Plan Information Annual Deductible/Individual $0 Annual Deductible/Family $0 Office Visit/Exam $10 copay Annual Out-of-Pocket Limit/Individual $750 Annual Out-of-Pocket Limit/Family $1,500 Lifetime Plan Maximum Unlimited Primary Care Physician Election Required Yes Preventive Services Well-Child Care 100% Immunizations 100% Well Woman Exams 100% Mammograms 100% Adult Periodic Exams with Preventive Tests 100% Diagnostic X-Ray and Lab Tests Maternity Care 100% preventive; $10 lab non preventive; No charge x-ray non preventive Pregnancy and Maternity Care (Pre-Natal Care) 100% Inpatient Hospital Services Inpatient Hospitalization 100% Pre-Authorization of Services Required Yes Semi-Private Room & Board; Including Services and Supplies 100% Surgical Services Outpatient Facility Charge 100% Emergency Services Emergency Room $30 copay waived if admitted Ambulance Air $30 Per trip Ground $30 Per trip Urgent Care Urgent Care Facility $15 copay The information described on this page is only intended to be a summary of benefits. It does not describe or include all benefit provisions, limitations, exclusions, or qualifications for coverage. Please review plan documents for full details. If there are any conflicts with information provided on this page, the plan documents will prevail. 8

11 Medical (continued) Benefit Categories Sutter Health Plus Schedule of Benefits Mental Health Benefits Inpatient Care 100% Outpatient Care $10 copay Individual; $5 copay Group Substance Abuse Inpatient Care Inpatient Hospitalization 100% Inpatient Detoxification Services 100% Outpatient Care Outpatient Services $10 copay Individual; $5 copay Group Prescription Drug Benefits Generic $5 copay Preferred Specialty 90% covered 30 days, share costs will not exceed $100 Brand (Formulary/Preferred) $20 copay Brand (Non-Formulary/Non-preferred) $40 copay Number of Days Supply 30 days Mail Order Generic $10 copay Preferred Specialty 90% covered 30 days, share of cost will not exceed $100 Brand (Formulary/Preferred) $40 copay Brand (Non-Formulary/Non-preferred) $80 copay Number of Days Supply for Mail Order 100 days Other Services and Supplies Durable Medical Equipment & Prosthetic Devices 100% Home Health Care 100% 100 days per calendar year Skilled Nursing or Extended Care Facility 100% 100 visits/ benefit period, prior authorization required Hospice Care 100% Chiropractic Services $10 copay; 20 visits Acupuncture Infertility $10 Typically provided only for the treatment of nausea or as part of comprehensive pain management Diagnosis Covered; see plan certificate Treatment Covered; see plan certificate Outpatient Rehabilitative Therapy Services Physical 100% Occupational 100% Speech 100% The information described on this page is only intended to be a summary of benefits. It does not describe or include all benefit provisions, limitations, exclusions, or qualifications for coverage. Please review plan documents for full details. If there are any conflicts with information provided on this page, the plan documents will prevail. 9

12 Dental When it comes to a dental plan, you want benefits that fit the needs of you and your family. Delta Dental PPO offers comprehensive dental coverage, quality care and excellent customer service. Delta Dental PPO Delta Dental PPO, our preferred provider organization (PPO) plan, provides access to the largest PPO Dentist network in the U.S. With this plan, you can access Dentists in both the PPO and Premier Networks (In-Network Dentists) for the lowest out-ofpocket costs. Dentists in these networks agree to accept reduced fees for the covered procedures when treating PPO patients. Because PPO Dentists have agreed to lower fees your out-of-pocket costs are usually lower when you visit a PPO Dentist than when you visit a non-delta Dental Dentist. You will see more discounts in the PPO network than in the Premier Network, but you have the freedom to visit any licensed Dentist, anywhere in the world. This matrix is a brief summary of your benefits. You must read the entire evidence of coverage in order to understand the details of your dental coverage. Delta Dental PPO Plan Dental PPO Dentist Delta Dental s Co-Payment Non-PPO Dentist Delta Dental s Co-Payment Waiting Period Calendar Year Maximum Calendar Year Deductible Diagnostic and Preventive Services 100% 100% None Basic Services 90% 80% None Crowns, Inlays, Onlays and Cast Restorations 70% 70% None Prosthodontic Services 50% 50% None $1,500 for each Enrollee There is no Deductible requirement Orthodontic Services for adults & children 50% 50% None $2,500 lifetime Maximum for each Enrollee For more information on Delta Dental please visit To look up a dental provider please visit The information described on this page is only intended to be a summary of benefits. It does not describe or include all benefit provisions, limitations, exclusions, or qualifications for coverage. Please review plan documents for full details. If there are any conflicts with information provided on this page, the plan documents will prevail. 10

13 Other Benefits Basic Life/AD&D, STD and LTD The City offers Life and Accidental Death & Dismemberment, Short Term Disability (STD) and Long Term Disability (LTD) to eligible employees. This benefit is offered through Standard Insurance Company. Basic Life and AD&D: Short-term Disability: 1 x annual earnings to $10,000 minimum; $100,000 maximum Benefit waiting period : (non-sworn) 29 days, (sworn) 59 days; 2/3 of salary to a maximum weekly benefit of $2,310 Long-term Disability: Benefit waiting period: (all full-time employees) 90 days; 2/3 of salary to a maximum monthly benefit of $10,000 Unemployment Insurance This benefit, which is offered through the State of California s Employment Development Department (EDD), allows you to receive funds in the event you become unemployed. 11

14 Employee Assistance Program (EAP) The offers an Employee Assistance Program (EAP) to all full-time employees through MHN. EAP benefits include: Problem- Solving Support (via face-to-face, phone or web video) Marriage, family and relationship issues Problems in the workplace Stress, anxiety, changes in mood, and sadness Grief, loss or responses to traumatic events Concerns about use of alcohol or drugs Work and Life Services Childcare and eldercare assistance Financial services Legal services Identity theft recovery services Daily living services Health and Wellness Tools Employees are entitled to eight (8) face-to-face sessions or telephonic or web-video consultations per incident, per plan period. 12

15 Retirement The pays into the California Public Employees Retirement System (CalPERS). All full-time and permanent part-time employees must make retirement contributions through bi-weekly payroll deductions. Rates of contributions are based on the employees represented unit. Retirement benefit amounts are calculated using the employee s service credit, benefit factor and final compensation. The current retirement formulas for miscellaneous (nonsworn) employees are: Tier One (Classic Members): Classic Formula 2.7@ age 55; final compensation will be based on any 12 highest consecutive months. Tier Two (PEPRA - new hires as of January 1, 2013): New Formula age 62; final compensation will be based on the average of 3 consecutive years prior to retirement date. The current retirement formulas for safety (sworn) employees are: Tier One (Classic Members): Classic Formula age 50; final compensation will be based on any 12 highest consecutive months. Tier Two (PEPRA - new hires as of January 1, 2013): New Formula age 57; final compensation will be based on the average of 3 consecutive years prior to retirement date. Retirement provisions for all employees include the following: An employee becomes vested in retirement system after 5 years of service. Employees in Tier One are eligible to retire as early as age 50. Employees in Tier Two are eligible to retire at age 52. Early retirement is subject to proration of retirement rates stated above. The employee pays the required employee contribution portion. This amount is deducted from your paycheck. The funds paid by the employee go into an account and earn interest. If you separate from employment for reasons other than retirement, you are entitled to withdraw these funds or if vested, leave them in the account and defer retirement. Employees who have service credit with other CalPERS agencies or have service in a reciprocal member agency will receive retirement benefits for those years based on the respective agency s retirement formula and final compensation. Retirees may receive a cost of living adjustment up to 2% per year. Employees retiring from the are entitled to automatically continue their medical coverage with the at the employee s expense. This benefit is subject to the employee s Memorandum of Understanding (MOU). Employees interested in learning more about their retirement may contact CalPERS directly at or visit the CalPERS website at calpers.ca.gov. Alternatively, employees may also contact the s Human Resources Department at Deferred Compensation and Roth IRA Full-time and permanent part-time employees can elect to participate in a voluntary 457 (b) retirement plan or a Roth IRA through ICMA-RC. The 457(b) reduces the employee s taxable income while providing savings for retirement. The benefits of a Roth IRA are that your contributions can grow tax-free and you can generally make withdrawals tax-and penalty-free after you reach age 59 ½. An employee can contribute as little as $10 per pay period up to the maximum IRS allowable limit per plan year. The City does not contribute or match the employee s contribution to either a 457 (b) plan or a Roth IRA. 13

16 Flexible Spending Accounts Flexible Spending Accounts are a great cost savings tool to help with common medical and/or dependent care expenses not covered by your insurance. You can elect a portion of your pay to be deducted, on a pre-tax basis, from each paycheck to use for reimbursements of qualified out-of-pocket expenses throughout the plan year. Health Flexible Spending Account (FSA) A Health Flexible Spending Account (FSA) allows you to allocate money on a pre-tax basis to reimburse yourself for qualified medical expenses for you and your family. Qualified expenses include copays, medical deductibles, prescriptions and much more. This does not include premium payments. The Maximum amount you may contribute to your FSA account in 2017 is $2,600. Partial List of Eligible Expenses (for a complete list of eligible expenses, please visit Copays / coinsurance Deductibles Dental treatments Diabetic supplies Prescription drugs and medicines Eye exams, eyeglasses, contact lenses, contact lens solution and enzyme Flu shots Immunizations Lab fees Laser / Lasik / RK surgery Medical exams Orthodontia Psychiatric care Wheelchair X-rays 14

17 Flexible Spending Accounts Dependent Care FSA A Dependent Care Account allows you to allocate money on a pre-tax basis to reimburse yourself for dependent care services such as after school care and dependent daycare centers. The minimum amount you may contribute to a Dependent Care Account for the plan year is $250; the maximum is $5,000. Partial List of Eligible Expenses (for a complete list of eligible expenses, please visit After-school care or extended day programs Nanny expenses Baby-sitter inside or outside participant s household Custodial or elder care expenses if the qualifying individual still spends at least eight (8) hours each day in the employee s household Dependent care center* expenses / pre-kindergarten / nursery school expense if primary purpose is to care for the child so the parent can work Expenses paid to a non-dependent relative of participant Summer day camp if the primary purpose of the expense is custodial in nature and not educational (excluding overnight facilities) Regardless of whether you participate in the dependent care plan under Section 125 or claim the credit on your income tax, you must provide the IRS with the name, address and taxpayer identification number (TIN) or Social Security number of your dependent care provider(s) by completing either Schedule 2 of Form 1040A or Form 2441 and attaching it to your annual income tax return. Be sure that you follow the current instructions given by the IRS for preparing your annual income tax return. Failure to provide this information to the IRS could result in loss of the pre-tax exemption for your dependent care expenses. FSA Fund Availability Health FSA Account Your full annual election is available to you on January 1st of the plan year. Dependent Care Account Unlike the Health FSA, the entire elected amount is not available on the first day of the plan year, but rather as contributions are received and services have been provided. Important FSA Notes If you are a new employee entering the plan during a plan year, services must be provided after you are eligible to participate in the plan. If you are enrolled in the Health FSA and take a leave of absence during the plan year, you may: 1. Prepay the contributions pre-tax, or 2. Continue the contributions on an after-tax basis (pre-tax contributions may continue when you return to work), or 3. Prorate the unpaid contributions over the remaining pay periods when you return to work. Failure to make all elected contributions will result in termination of your account as of the date contributions ceased. You may roll over up to $500 per year in unused funds. * A Dependent Care Center is a place that provides care for more than six persons (other than persons who live there) and receives a fee, payment or grant for providing services for any of those persons, regardless of whether the center is run for profit. 15

18 Miscellaneous Important Notices Special Enrollment Rights Notice CHANGES TO YOUR HEALTH PLAN ELECTIONS Once you make your benefits elections, they cannot be changed until the next Open Enrollment. Open Enrollment is held once a year. If you are declining enrollment for yourself or your Dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your Dependents in this plan if there is a loss of other coverage. However, you must request enrollment no later than 30 days after that other coverage ends. If you declined coverage while Medicaid or CHIP is in effect, you may be able to enroll yourself and / or your Dependents in this plan if you or your Dependents lose eligibility for that other coverage. However, you must request enrollment no later than 60 days after Medicaid or CHIP coverage ends. If you or your Dependents become eligible for Medicaid or CHIP premium assistance, you may be able to enroll yourself and / or your Dependents into this plan. However, you must request enrollment no later than 60 days after the determination for eligibility for such assistance. If you have a change in family status such as a new Dependent resulting from marriage, birth, adoption or placement for adoption, divorce (including legal separation and annulment), death or Qualified Medical Child Support Order, you may be able to enroll yourself and / or your Dependents. However, you must request enrollment no later than 30 days after the marriage, birth, adoption or placement for adoption or divorce (including legal separation and annulment). COBRA Continuation Coverage This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage. 16

19 Important Notices (continued) The right to COBRA continuation coverage was created by federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan s Summary Plan Description or contact the Plan Administrator. Your spouse s employment ends for any reason other than his or her gross misconduct; Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or You become divorced or legally separated from your spouse. You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30- day special enrollment period for another group health plan for which you are eligible (such as a spouse s plan), even if that plan generally doesn t accept late enrollees. WHAT IS COBRA CONTINUATION COVERAGE? COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a Qualifying Event. Specific Qualifying Events are listed later in this notice. After a Qualifying Event, COBRA continuation coverage must be offered to each person who is a Qualified Beneficiary. You, your spouse, and your Dependent children could become Qualified Beneficiaries if coverage under the Plan is lost because of the Qualifying Event. Under the Plan, Qualified Beneficiaries who elect COBRA continuation cover must pay for COBRA continuation coverage. If you re an Employee, you ll become a Qualified Beneficiary if you lose coverage under the Plan because of the following Qualifying Events: Your hours of employment are reduced, or Your employment ends for any reason other than your gross misconduct. If you re the spouse of an Employee, you ll become a Qualified Beneficiary if you lose your coverage under the Plan because of the following Qualifying Events: Your spouse dies; Your spouse s hours of employment are reduced; Your Dependent children will become Qualified Beneficiaries if they lose coverage under the Plan because of the following Qualifying Events: The parent-employee dies; The parent-employee s employment ends for any reason other than his or her gross misconduct; The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); The parents become divorced or legally separated; or The child stops being eligible for coverage under the Plan as a dependent child. WHEN IS COBRA CONTINUATION COVERAGE AVAILABLE? The Plan will offer COBRA continuation coverage to Qualified Beneficiaries only after the Plan Administrator has been notified that a Qualifying Event has occurred. The Employer must notify the Plan Administrator of the following Qualifying Events: The end of employment or reduction of hours of employment; Death of the Employee; or The Employee s becoming entitled to Medicare benefits (under Part A, Part B, or both). For all other Qualifying Events (e.g. divorce or legal separation of the Employee and spouse or a Dependent child s losing eligibility for coverage as a Dependent child), you must notify the Plan Administrator within 60 days after the Qualifying Event occurs. You must provide this notice to Human Resources. 17

20 Important Notices (continued) Life insurance, accidental death and dismemberment benefits and weekly income or long-term disability benefits (if part of the Employer s Plan) are not eligible for continuation under COBRA. NOTICE AND ELECTION PROCEDURES Each type of notice or election to be provided by a Covered Employee or a Qualified Beneficiary under this COBRA Continuation Coverage Section must be in writing, must be signed and dated, and must be furnished by U.S. mail, registered or certified, postage prepaid and properly addressed to the Plan Administrator. Each notice must include all of the following items: the Covered Employee s full name, address, phone number and Social Security number; the full name, address, phone number and Social Security number of each affected Dependent, as well as the Dependent s relationship to the Covered Employee; a description of the Qualifying Event or disability determination that has occurred; the date the Qualifying Event or disability determination occurred on; a copy of the Social Security Administration s written disability determination, if applicable; and the name of this Plan. The Plan Administrator may establish specific forms that must be used to provide a notice or election. ELECTION AND ELECTION PERIOD COBRA continuation coverage may be elected during the period beginning on the date Plan coverage would otherwise terminate due to a Qualifying Event and ending on the later of the following: (1) 60 days after coverage ends due to a Qualifying Event, or (2) 60 days after the notice of the COBRA continuation coverage rights is provided to the Qualified Beneficiary. If, during the election period, a Qualified Beneficiary waives COBRA continuation coverage rights, the waiver can be revoked at any time before the end of the election period. Revocation of the waiver will be an election of COBRA continuation coverage. However, if a waiver is revoked, coverage need not be provided retroactively (that is, from the date of the loss of coverage until the waiver is revoked). Waivers and revocations of waivers are considered to be made on the date they are sent to the Employer or Plan Administrator. HOW IS COBRA CONTINUATION COVERAGE PROVIDED? Once the Plan Administrator receives notice that a Qualifying Event has occurred, COBRA continuation coverage will be offered to each of the Qualified Beneficiaries. Each Qualified Beneficiary will have an independent right to elect COBRA continuation coverage. Covered Employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain Qualifying Events, or a second Qualifying Event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage. DISABILITY EXTENSION OF THE 18-MONTH PERIOD OF COBRA CONTINUATION COVERAGE If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. This disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage. SECOND QUALIFYING EVENT EXTENSION OF 18-MONTH PERIOD OF COBRA CONTINUATION COVERAGE If your family experiences another Qualifying Event during the 18 months of COBRA continuation of coverage, the spouse and Dependent children in your family can get up to 18 additional months of COBRA continuation of coverage, for a maximum of 36 months, if the Plan is properly notified about the second Qualifying Event. This extension may be available to the spouse and any Dependent children receiving COBRA continuation of coverage if the Employee or former Employee dies; becomes entitled to Medicare (Part A, Part B, or both); gets divorced or legally separated; or if the Dependent child stops being eligible under the Plan as a Dependent child. This extension is only available if the second Qualifying Event would have caused the spouse or the Dependent child to lose coverage under the Plan had the first Qualifying Event not occurred. OTHER OPTION BESIDES COBRA CONTINUATION COVERAGE Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse s plan) through what is called a special enrollment period. Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at 18

21 Important Notices (continued) IF YOU HAVE QUESTIONS For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor s Employee Benefits Security Administration (EBSA) in your area or visit (Address and phone numbers of Regional and District EBSA Offices are available through EBSA s website.) For more information about the Marketplace, visit KEEP YOUR PLAN INFORMED OF ADDRESS CHANGES To protect your family s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. EFFECTIVE DATE OF COVERAGE COBRA continuation coverage, if elected within the period allowed for such election, is effective retroactively to the date coverage would otherwise have terminated due to the Qualifying Event, and the Qualified Beneficiary will be charged for coverage in this retroactive period. COST OF CONTINUATION COVERAGE The cost of COBRA continuation coverage will not exceed 102% of the Plan s full cost of coverage during the same period for similarly situated non-cobra Beneficiaries to whom a Qualifying Event has not occurred. The full cost includes any part of the cost which is paid by the Employer for non-cobra Beneficiaries. The Plan will allow the payment for COBRA continuation coverage to be made in monthly installments but the Plan can also allow for payment at other intervals. The Plan is not obligated to send monthly premium notices. The Plan will notify the Qualified Beneficiary in writing, of any termination of COBRA coverage based on the criteria stated in this subsection that occurs prior to the end of the Qualified Beneficiary s applicable maximum coverage period. Notice will be given within 30 days of the Plan s decision to terminate. Such notice shall include the reason that continuation coverage has terminated earlier than the end of the maximum coverage period for such Qualifying Event and the date of termination of continuation coverage. See the Summary Plan Description for more information. Newborns and Mothers Health Protection Act (NMHPA) A health plan which provides benefits for pregnancy delivery generally may not restrict benefits for a covered pregnancy Hospital stay (for delivery) for a mother and her newborn to less than 48 hours following a vaginal delivery or 96 hours following a Cesarean section. Also, any utilization review requirements for Inpatient Hospital admissions will not apply for this minimum length of stay and early discharge is only permitted if the attending health care provider, in consultation with the mother, decides an earlier discharge is appropriate. The initial payment must be made within 45 days after the date of the COBRA election by the Qualified Beneficiary. Payment must cover the period of coverage from the date of the COBRA election retroactive to the date of loss of coverage due to the Qualifying Event (or date a COBRA waiver was revoked, if applicable). The first and subsequent payments must be submitted and made payable to the Plan Administrator or COBRA Administrator. Payments for successive periods of coverage are due on the first of each month thereafter, with a 30-day grace period allowed for payment. Where an Employee organization or any other entity that provides Plan benefits on behalf of the Plan Administrator permits a billing grace period later than the 30 days stated above, such period shall apply in lieu of the 30 days. Payment is considered to be made on the date it is sent to the Plan or Plan Administrator. 19

22 Important Notices (continued) Health Insurance Marketplace Coverage Options and Your Health Coverage PART A: GENERAL INFORMATION This notice provides you with information about the City of El Cerrito s Plan in the event you wish to apply for coverage on the Health Insurance Marketplace. All the information you need from Human Resources is listed in this notice. If you wish to have someone assist you in the application process or have questions about subsidies that you may be eligible to receive, you can contact KeenanDirect at or at KeenanDirect.com, or contact the Health Insurance Marketplace directly at HealthCare. gov. WHAT IS THE HEALTH INSURANCE MARKETPLACE? The Marketplace offers one-stop shopping to find and compare private health insurance options. You may also be eligible for a tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins November 1, 2016 and ends on January 31, CAN I SAVE MONEY ON MY HEALTH INSURANCE PREMIUMS IN THE MARKETPLACE? You may qualify to save money and lower your monthly premium, but only if your employer does not offer you coverage, or offers medical coverage that is not Affordable or does not provide Minimum Value. If the lowest cost plan from your employer that would cover you (and not any other members of your family) is more than 9.5% of your household income for the year, then that coverage is not Affordable. Moreover, if the medical coverage offered covers less than 60% of the benefits costs, then the plan does not provide Minimum Value. DOES EMPLOYER HEALTH COVERAGE AFFECT ELIGIBILITY FOR PREMIUM SAVINGS THROUGH THE MARKETPLACE? Yes. If you have an offer of medical coverage from your employer that is both Affordable and provides Minimum Value, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer s medical plan. Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer-offered medical coverage. Also, this employer contribution, as well as your employee contribution to employeroffered coverage, is often excluded from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis. PART B: EXCHANGE APPLICATION INFORMATION In the event you wish to apply for coverage on the Exchange, all the information you need from Human Resources is listed below. If you wish to have someone assist you in the application process or have questions about subsidies that you may be eligible to receive, you can contact KeenanDirect at or at KeenanDirect.com. 3. Employer name 4. Employer Identification Number (EIN) Employer address San Pablo Avenue 6. Employer phone number City El Cerrito 8. State CA 9. ZIP code Who can we contact about employee health coverage at this job? Cheryl Mosby 11. Phone number (if different from above) 12. address jobs@ci.el-cerrito.ca.us 20

23 Important Notices (continued) Premium Assistance under Medicaid and the Children s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren t eligible for Medicaid or CHIP, you won t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www. healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial KIDS NOW or to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employersponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren t already enrolled. This is called a special enrollment opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at or call EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, Contact your State for more information on eligibility. ALABAMA Medicaid ALASKA Medicaid The AK Health Insurance Premium Payment Program CustomerService@MyAKHIPP.com Medicaid Eligibility: ARKANSAS Medicaid MyARHIPP ( ) COLORADO Medicaid FLORIDA Medicaid GEORGIA Medicaid Click on Health Insurance Premium Payment (HIPP) INDIANA Medicaid Healthy Indiana Plan for low-income adults All other Medicaid IOWA Medicaid KANSAS Medicaid KENTUCKY Medicaid LOUISIANA Medicaid MAINE Medicaid html TTY: Maine relay 711 MASSACHUSETTS Medicaid and CHIP MINNESOTA Medicaid MISSOURI Medicaid MONTANA Medicaid

24 Important Notices (continued) NEBRASKA Medicaid AccessNebraska/Pages/accessnebraska_index.aspx NEVADA Medicaid NEW HAMPSHIRE Medicaid TEXAS Medicaid UTAH Medicaid and CHIP Medicaid Website: CHIP Website: VERMONT Medicaid NEW JERSEY Medicaid and CHIP Medicaid: dmahs/clients/medicaid/ CHIP: NEW YORK Medicaid NORTH CAROLINA Medicaid NORTH DAKOTA Medicaid VIRGINIA Medicaid and CHIP Medicaid: cfm CHIP: cfm WASHINGTON Medicaid index.aspx ext WEST VIRGINIA Medicaid Pages/default.aspx , HMS Third Party Liability OKLAHOMA Medicaid and CHIP OREGON Medicaid PENNSYLVANIA Medicaid RHODE ISLAND Medicaid SOUTH CAROLINA Medicaid SOUTH DAKOTA - Medicaid WISCONSIN Medicaid and CHIP pdf WYOMING Medicaid To see if any other states have added a premium assistance program since July 31, 2016, or for more information on special enrollment rights, contact either: U.S. Department of Labor Employee Benefits Security Administration dol.gov/ebsa EBSA (3272) U.S. Department of Health and Human Services Centers for Medicare and Medicaid Services cms.hhs.gov , Menu Option 4, ext

25 Notes 23

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